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Open AccessResearch Adaptation costs for climate change-related cases of diarrhoeal disease, malnutrition, and malaria in 2030 Kristie L Ebi Address: ESS, LLC, Alexandria, VA 22304, USA

Open Access

Research

Adaptation costs for climate change-related cases of diarrhoeal

disease, malnutrition, and malaria in 2030

Kristie L Ebi

Address: ESS, LLC, Alexandria, VA 22304, USA

Email: Kristie L Ebi - krisebi@essllc.org

Abstract

Background: Climate change has begun to negatively affect human health, with larger burdens

projected in the future as weather patterns continue to change The climate change-related health

consequences of diarrhoeal diseases, malnutrition, and malaria are projected to pose the largest

risks to future populations Limited work has been done to estimate the costs of adapting to these

additional health burdens

Methods: The costs of treating diarrhoeal diseases, malnutrition (stunting and wasting only), and

malaria in 2030 were estimated under three climate scenarios using (1) the current numbers of

cases; (2) the projected relative risks of these diseases in 2030; and (3) current treatment costs

The analysis assumed that the number of annual cases and costs of treatment would remain

constant There was limited consideration of socioeconomic development

Results: Under a scenario assuming emissions reductions resulting in stabilization at 750 ppm CO2

equivalent in 2210, the costs of treating diarrhoeal diseases, malnutrition, and malaria in 2030 were

estimated to be $4 to 12 billion This is almost as much as current total annual overseas

development assistance for health

Conclusion: The investment needs in the health sector to address climate-sensitive health

outcomes are large Additional human and financial resources will be needed to prevent and

control the projected increased burden of health outcomes due to climate change

Background

The health impacts of climate change are diverse and

wide-ranging Weather and climate are among the factors

that determine the geographic range and incidence of

sev-eral major causes of ill health, including undernutrition,

which affects 17% of the world's population in

develop-ing countries [1]; diarrhoeal diseases and other conditions

due to unsafe water and lack of basic sanitation, which

cause 2 million deaths annually, mostly in young children

[2]; and malaria, which causes more than a million

child-hood deaths annually [3] Table 1 provides the annual

incidence of diarrhoeal disease, malnutrition, and malaria

by WHO Region in 2002 [countries included in each region are provided in Additional file 1] The numbers for malnutrition include only stunting and wasting, not all the health impacts, and do not include micronutrient deficiencies, such as of zinc and vitamin A, that also have serious health consequences

The Fourth Assessment Report of the Intergovernmental Panel on Climate Change concluded that climate change has begun to negatively affect human health, and that

pro-Published: 19 September 2008

Globalization and Health 2008, 4:9 doi:10.1186/1744-8603-4-9

Received: 31 August 2007 Accepted: 19 September 2008 This article is available from: http://www.globalizationandhealth.com/content/4/1/9

© 2008 Ebi; licensee BioMed Central Ltd

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

jected climate change will increase the risks of

climate-sensitive health outcomes [4] The climate change-related

health consequences of malnutrition, diarrhoeal diseases,

and malaria are projected to pose large risks to future

pop-ulations, particularly in low-income countries in tropical

and sub-tropical regions

The size of the projected impacts raises the question of

how much it will cost to treat these additional cases of

dis-ease To further the discussion of adaptation costs, this

paper estimates of the costs of interventions to cope with

additional cases of malnutrition, diarrhoeal diseases, and

malaria due to climate change in 2030 The estimates are

for the costs of climate change only Population growth is

not considered and there is limited consideration of

soci-oeconomic development

Methods

The data sources used were (1) the current number of

cases of diarrhoeal diseases, malnutrition, and malaria

[http://www.who.int/healthinfo/bodestimates/en/

index.html; accessed 20 May 2007]; (2) the World Health

Organization (WHO) Global Burden of Disease (GBD)

study that projected the relative risks associated with

cli-mate change in 2030 for a range of clicli-mate-sensitive

health determinants and outcomes [5]; and (3) published

data on the costs of interventions for diarrhoeal diseases,

malnutrition, and malaria, primarily from the project

'Disease Control Priorities in Developing Countries' http:/

/www.dcp2.org Assuming that the current annual

number of cases of diarrhoeal diseases, malnutrition, and

malaria would remain constant to 2030, the numbers of

current cases were multiplied by the relative risks for

cli-mate change esticli-mated by the Global Burden of Disease

Study (under three different emission scenarios) to

esti-mate the number of additional cases of these diseases that could be attributed to climate change in the year 2030 The numbers of additional cases were multiplied by the current costs of treatment per case to estimate the addi-tional costs of treating climate change-related cases of diarrhoeal diseases, malnutrition, and malaria

WHO Global Burden of Disease study

The goals of the World Health Organization (WHO) Glo-bal Burden of Disease study were to produce the best pos-sible evidence-based description of population health, the causes of lost health, and likely future trends in health in order to inform policy-making [6] Twenty-six risk factors, including climate change, were assessed [5] The GBD used two summary measures of population health, mor-tality and the Disability Adjusted Life Years lost (DALYs) DALYs provide a better measure than mortality of the population health impacts of diarrhoeal diseases, malnu-trition, and malaria The attributable burden of DALYs for

a specific risk factor was determined by estimation of the burden of specific diseases related to the risk factor; esti-mation of the increase in risk for each disease per unit increase in exposure to the risk factor; and estimation of the current population distribution of exposure, or future distribution as estimated by modelling exposure scenar-ios Counterfactual or alternative exposure scenarios to the current distribution of risk factors were created to explore distributional transitions towards a theoretical minimum level of exposure (e.g for exposure to carcino-gens, the theoretical minimum level of exposure would be

no exposure)

For climate change, the questions addressed were what will be the total health impact caused by climate change between 2000 and 2030 and how much of this burden

Table 1: Annual incidence of diarrhoeal diseases, malnutrition (stunting and wasting) and malaria by WHO sub-region, 2002

Sub-region Population (000s) Diarrhoeal diseases (000s) Malnutrition (000s) Malaria (000s) Total (000s)

Source: http://www.who.int/healthinfo/bodestimates/en/index.html; accessed 20 May 2007

could be avoided by stabilizing greenhouse gas emissions

[5] The alternative exposure scenarios defined were:

• Unmitigated emission trends (i.e., approximately

fol-lowing the Intergovernmental Panel on Climate Change

IS92a or business as usual scenario);

• Emissions reductions resulting in stabilization at 750

ppm CO2 equivalent by 2210 (s750); and

• Emissions reductions resulting in stabilization at 550

ppm CO2 equivalent by 2170 (s550)

Climate change projections were generated by the

HadCM2 general circulation climate model [7] The

health outcomes included in the analysis were chosen

based on sensitivity to climate variation, predicted future

importance, and availability of quantitative global

mod-els (or feasibility of constructing them) The health

out-comes selected were the direct impacts of heat and cold,

episodes of diarrhoeal disease, cases of Plasmodium

falci-parum malaria, fatal unintentional injuries in coastal

floods and inland floods/landslides, and non-availability

of recommended daily calorie intake (as an indicator for

the prevalence of malnutrition) Global and WHO

spe-cific region estimates were generated

In the year 2000, the mortality attributable to climate

change was estimated to be 154,000 (0.3%) deaths, and

the attributable burden was 5.5 million (0.4%) DALYs,

with approximately 50% of the burden due to

malnutri-tion [5] About 46% of the DALYs attributable to climate

change were estimated to have occurred in the WHO

South-East Asia Region, 23% in countries in the Africa

region with high child mortality and very high adult male

mortality, and 14% in countries in the Eastern

Mediterra-nean region with high child and adult male mortality

Additional files 2, 3, 4, provide the relative risk estimates

for malnutrition, diarrhoeal diseases, and malaria,

respec-tively, projected for 2030 under the alternative exposure

scenarios [5] Lower range relative risk estimates are not

shown as they were 1.00 or close to 1.00

For diarrhoeal diseases, developing countries were

defined as those with per capita incomes less than

US$6,000/year in 1990 US dollars [5] For such countries,

the exposure-response relationship used was a 5%

increase in diarrhoeal incidence per °C increase in

tem-perature The study assumed that the climate sensitivity of

diarrhoea would decrease with increasing GDP; once a

country was projected to reach per capita incomes of

UD$6,000/year (as estimated by EMF 14 [8]), then overall

diarrhoea incidence was assumed to not respond to

changes in temperature The study assumed that

diar-rhoeal incidence in richer countries is insensitive to cli-mate change The relative risks for each region are a population-weighted average of the countries within the region

For malnutrition, estimates of national food availability were based on the effects of temperature and precipita-tion, and the beneficial effects of higher CO2 levels, pro-jected using the IBSNAT-ICASA dynamic crop growth models [9] Principal characteristics of this model include

no major changes in the political or economic context of world food trade or in food production technology; pop-ulation growth follows the World Bank mid-range esti-mate (i.e 10.7 billion by the 2080s); GDP accumulated as projected by EMF14 [8]; and a 50% trade liberalization in agriculture is introduced gradually by 2020

Analyses suggested that the model output was positively related to more direct measures of malnutrition, including incidence of underweight, and stunting and wasting in children <5 years of age [5] The relative risks of malnutri-tion in Addimalnutri-tional file 3 were interpreted as being directly proportional to underweight; this applies to all diseases affected by underweight (including diarrhoea and malaria) The model output was used to generate mid-range estimates; the high relative risks were calculated as a doubling of the mid-range estimate

For malaria, estimates for the projected populations at risk

of Plasmodium falciparum malaria were based on the

MARA/ARMA model [5] The model output was used to generate mid-range estimates; the high relative risks were calculated as a doubling of the mid-range estimate Socio-economic development was assumed to not affect the incidence of malaria

Results

Estimated climate change-related excess incident cases of diarrhoeal diseases, malnutrition, and malaria in 2030

The total estimated excess incident cases of diarrhoeal dis-eases, malnutrition, and malaria in 2030 for the three sce-narios (unmitigated emissions and stabilization at 550 and 750 ppm CO2 equivalent) are shown in Tables 2, 3 and 4 Given the current burden of these health outcomes and the relative risks from the Global Burden of Disease study, it is not surprising that the largest increases in cli-mate change-attributable cases are projected to be in Africa and Southeast Asia Table 5 compares current and projected (under the 750 ppm CO2 scenario) numbers of cases of diarrhoeal diseases, malnutrition, and malaria; climate change is projected to increase the numbers of cases by 3–10% Smaller increases were projected under the lower emission scenarios

Annual costs of interventions for diarrhoeal diseases,

malnutrition, and malaria

Annual costs of intervention for diarrhoeal diseases,

mal-nutrition, and malaria http://www.dcp2.org were based

on currently deployed interventions and did not include

costs of implementing programs (including infrastructure

and health care personnel costs) in new areas if these

dis-eases increase their geographic range, as is projected The

costs of initiating programs in new areas can be

signifi-cant, and include costs of infrastructure (i.e building clin-ics, costs for equipment and drugs), training new personnel, maintenance costs, etc Excluding the costs of implementing programs that are currently being scaled up across Africa with the help of the Global Fund, the US President's Malaria Initiative, and others, substantially underestimates the cost of controlling malaria

Table 2: Projected excess incident cases of diarrhoeal diseases

(000s) for alternative climate scenarios relative to baseline

climate (mid and high estimates)

Sub-region Climate 2000 2030

Table 3: Projected excess incident cases of malnutrition (000s) for alternative climate scenarios relative to baseline climate (mid and high estimates)

Sub-region Climate 2000 2030

There are three major diarrhoea syndromes requiring treatment: acute watery diarrhoea that results in varying degrees of dehydration; persistent diarrhoea that last 14 days or longer, manifested by malabsorption, nutrient losses, and wasting; and bloody diarrhoea caused by inflammation of the intestinal tract Viruses, bacteria, pro-tozoa, and helminthes can cause diarrhoea Diarrhoeal diseases affect all populations, with the largest health bur-dens among the poor The costs of two sets of intervention for treating diarrhoeal diseases in children under five were estimated: (1) breastfeeding promotion, rotavirus immu-nization, cholera immuimmu-nization, and measles immuniza-tion; and (2) improvement of water supply and sanitation [10] The average cost per child in 2001 US$ for (1) was

$15.09 (the costs range from $0.71 per child for oral rehy-dration therapy in Indonesia to $104.30 per child for rota-virus immunization in South Africa) and for (2) was

$53.00 ($25.00 for rural areas and $81.00 for urban areas)

The average costs of nutritional interventions per child for addressing underweight range from $17.40 to $23.09, and include breastfeeding promotion, child survival grams (with a nutritional component), nutritional pro-grams, and growth monitoring and counselling [11] These costs are very conservative; Edejer et al [12] esti-mated the annual per capita cost of providing food to improve child health in Africa D and SEAR-D was $int (international dollar) 116.23, and the cost per recipient was $int 310.91 to 317.30 An international dollar is a hypothetical unit of currency that has the same purchas-ing power that the US$ has in the US at a given point in time, thus showing the average value of local currency units within each region's borders Using these estimates would increase the estimated costs by more than 10-fold

The costs of two sets of interventions for malaria were esti-mated: (1) insecticide-treated bednets plus case manage-ment with artemisinin-based combination therapy plus intermittent presumptive treatment in pregnancy; and (2) indoor residual spraying plus (1) [13] The average cost for (1) for Africa D and E was $int 88.50 and the average cost for (2) was $int 123.5; these are incremental costs per disability adjusted life year lost and did not include the costs of implementing new malaria control programs These cost estimates are not on the same basis as those for

Table 4: Projected excess incident cases of malaria (000s) for

alternative climate scenarios relative to baseline climate (mid

and high estimates)

Sub-region Climate 2000 2030

Table 5: Comparison of current diarrhoeal disease, malnutrition, and malaria cases with estimated additional cases due to climate change in 2030 assuming the 750 ppm of CO 2 scenario (thousands of cases)

Diarrhoeal diseases Malnutrition Malaria

diarrhoeal diseases and malnutrition (which were for the

cost of treatment intervention per child); however, no

adjustments were made in the analysis

Table 6 summarizes the projected excess costs in millions

of US$ in 2030 to manage the excess cases of diarrhoeal

diseases, malnutrition, and malaria due to climate change

under the three scenarios The total costs under S550 were

estimated to be $3,333 to $10,689 million; the total costs

under S750 were $3,992 to $12,603 million; and the total

costs under UE were $5,852 to $17,957 million

Current health expenditures

Poor countries tend to have low health expenditures and

to rely significantly on external donors [3] Currently,

there are a number of donors interested in investing in

health, which is increasing overseas development

assist-ance Bilateral assistance for health rose from an annual

average of US$ 2.2 billion during 1997–99 to US$ 2.9

bil-lion in 2002 (Table 7) [14] Within the UN system,

devel-opment assistance rose from an annual average of US$ 1.6

billion during 1997–99 to US$ 2 billion in 2002

Com-mitments from the development banks remained

station-ary at about US$ 1.4 billion However, changes in

accounting at the World Bank to include financing for

health-related activities in other sectors (i.e water and

sanitation, transportation, and social development),

sug-gest that new commitments rose from about US$ 1 billion

in 2001 to US$ 1.7 billion in 2003

Therefore, for the 750 ppm CO2 scenario, the annual

needs in 2030 would be almost as much as current total

annual overseas development assistance for health The

estimate of investment needs does not account for

socio-economic changes, in particular increased population and

income Assuming the estimated costs of treatment per

case do not differ between baseline cases and cases due to

climate change, the total investment needs in 2030 for

combating diarrhoeal disease would be $67 billion,

mal-nutrition $2 billion, and malaria $36 to $50 billion

Discussion

Estimating the adaptation needs in the health sector is

challenging Most of the health outcomes that are

pro-jected to be affected by climate change are current prob-lems; there will not be death certificates, hospital admissions, or records of visits to health care providers indicating that a particular event was due to climate change Instead, as with some other environmental expo-sures (particularly indoor and outdoor air quality), mod-els are used to estimate the proportion of a disease burden that can be attributed to climate change based on expo-sure-response relationships and projected changes in weather patterns Uncertainties in models, from limited data through to inadequate specification of factors that influence the exposure-response relationship, will there-fore lead to uncertainty as to the precise magnitude of the climate change impact

The analysis makes a number of necessary, but unlikely assumptions, including that the number of annual cases

of diarrhoeal disease, malaria, and malnutrition, and the cost of treatment would remain constant Population growth is projected to increase under the medium variant from 6.1 billion in 2000 to 8.3 billion in 2030 [15] Con-ducting a sensitivity analysis that incorporated these pop-ulation increases would require assumptions of future incidence rates of these health outcomes, based on assumptions of socioeconomic development, including improvements in health care delivery, the rate of deploy-ment of current interventions, and the developdeploy-ment of more effective technologies Using the current number of cases in the analysis in effect assumes that incidence will decrease as population increases, without attribution of the possible reasons for such a decline If disease rates remain constant until 2030, then the number of cases due

to climate change would increase

Because of the large uncertainties, the costs estimated should be viewed only as indicators of the relative magni-tude of health adaptation costs Countries improve their public health and health care systems as they develop, which should decrease the burden of many climate-sensi-tive diseases Costs of current treatments tend to decrease over time, although development of new, more effective treatments may cost more However, there is an underly-ing assumption that currently developunderly-ing countries will develop along similar pathways to those followed by the

Table 6: Projected excess costs (million US$) in 2030 to manage climate change-related cases of diarrhoeal diseases, malnutrition, and malaria for three alternative climate scenarios relative to baseline climate (mid and high estimates)

Scenario Diarrhoeal Diseases Malnutrition Malaria

developed countries There is ample evidence to suggest

that the reality may be much more challenging A key

issue is water; most developing countries do not have as

much available water as developed countries did when

they were developing Therefore, it will be more difficult

to resolve issues such as access to safe water and

sanita-tion Also, malaria is much more difficult to control in

Africa than it was in Europe and the US

Another complexity is estimating the economic cost of

injuries, illnesses, and deaths across multiple countries

and regions Issues include not just how to value a human

life, but how to measure economically the life-course

con-sequences of malnutrition, for example Mortality is a

commonly used metric, but is an inadequate measure of

the affect of a health outcome on the family and on

soci-ety; a death at age 80 and a death at age 2 would be

counted equally while having different impacts Similarly,

malnutrition decreases learning ability, thus affecting

life-long earning potential, among a myriad of other impacts

Therefore, counting cases of disease also is insufficient for

estimating total impacts

Additional research could reduce some of the

uncertain-ties in the analysis The literature base underlying the

exposure-response relationships is fairly thin; additional

estimates in more regions would increase confidence in

projected relative risks and would allow estimates of

future climate change-attributable cases on smaller spatial

scales Additional research also is needed to better project

how population growth, socioeconomic development,

and other factors would likely influence future rates of

cli-mate-sensitive health determinants and outcomes

Devel-opment of a health model would facilitate both

projections and identification where additional

informa-tion would reduce uncertainty [16] Linking such a model

with integrated assessment models would take advantage

of the their efforts to model population growth and

eco-nomic development

Bosello et al [17] estimated the economic impacts of

cli-mate change in 2050 on temperature-related illnesses,

diarrhoeal diseases, malaria, dengue fever, and

schisto-somiasis Changes in morbidity and mortality were

inter-preted as changes in labour productivity and demand for health care There was a mixed pattern of increases and decreases in GDP, welfare, and investment across world regions, with benefits estimated in high-income countries and losses primarily in low-income countries The results showed that direct cost estimates, such as the present anal-ysis, underestimate the full health costs (and benefits) of climate change

Because of the uncertainties in the estimated costs, they should be taken as indicators of the size of the financial needs and not as accurate predictions The estimates are likely to include both under- and over-estimates of the actual costs Emerging technologies, along with signifi-cant investments in research and development, are likely

to reduce current health burdens over the next 20+ years

On the other hand, the estimated costs were for only three

of the health outcomes projected to increase with climate change; and then only a fraction of the burden of malnu-trition was included According to Caulfied et al [11], the estimated prevalence of weight-for-age less than -2 SD (a measure of malnutrition) are 18% for Asia and the Pacific; 6% for Eastern Europe and Central Asia, and for Latin America and the Caribbean; 21% for the Middle East and North Africa; 46% in South Asia; 32% in Sub-Saharan Africa; and 2% in high-income countries In addition, the model used to estimate malnutrition does not take into account new projections that a few degree increase in glo-bal mean temperature may render some areas unsuitable for rainfed agriculture; if this occurs, the short-term health consequences would likely be severe

The costs estimated for adaptation are consistent with other estimates of financial needs for health care invest-ment Stenberg et al [18] estimated the costs to scale-up essential child health interventions to reduce by two-thirds child mortality under the four MDGs aimed at chil-dren's health by 2015 in 75 countries; the countries cho-sen accounted for 94% of death among children less than five years of age The interventions focused on malnutri-tion, pneumonia, diarrhoea, malaria, and key newborn causes of death Calculations were bottom-up, based on intervention, country, and year Costs included program-specific investments needed at national and district levels

Table 7: Development assistance for health, selected years (millions US$)

Source Annual Average, 1997–1999 2002

Source: Hecht and Shah [14]

The authors estimated that an additional US$ 52.4 billion

would be required for the period 2006–2015 Projected

costs in 2015 were equivalent to increasing the average

total health expenditures from all financial resources in

the 75 countries by 8% and raising general government

health expenditure by 26% over 2002 levels The authors

noted that countries with weak health care systems may

experience difficulties mobilizing enough domestic

pub-lic funds

Kiszewski et al [19] estimated that US$ 38 to 45 billion

would be required from 2006 to 2015 to scale up current

malaria control programs to reach international goals, or

about US$ 3.8 to 4.5 billion annually If resources were to

be made available and malaria goals were achieved, then

the numbers of climate change-related cases of malaria in

2030 would likely to significantly lower, thus requiring

fewer additional resources for treatment than the

esti-mated US$ 4 – 12 billion under the 750 ppm CO2

sce-nario

Although current governmental health expenditures can

be anticipated to increase with development, there are

health problems other than those associated with climate

change that need to be addressed, such as HIV/AIDS,

tuberculosis, diabetes, and other diseases Assuming that

Ministries of Health, NGOs, and other actors will

com-pletely cover the additional costs related to climate change

is not realistic for many low-income countries; to do so

would mean that other health issues of importance are left

wanting Financial and policy arrangements will need to

be altered to address the projected additional cases of

diarrhoeal diseases, malnutrition, and malaria

Conclusion

Overall, progress is being made in controlling

climate-sensitive health outcomes However, much of the progress

has been in areas where the health outcomes are easier to

control The world is not on track to meet the

health-related MDGs by 2015, with climate change working

against disease control efforts

Because the needs for investment in the health sector are

large, capacity needs to be built to address

climate-sensi-tive health outcomes There needs to be increased

aware-ness among Ministries of Health and donors of how

climate change could alter the burden of a range of health

outcomes, so that appropriate modifications are made in

current programs to better address these health outcomes

to increase future adaptive capacity Additional human

and financial resources will be needed to prevent and

con-trol the projected increased burden of health outcomes

due to climate change

Abbreviations

CO2: carbon dioxide; DALYs: Disability Adjusted Life Years; EMF: Energy Modelling Forum; MDGs: Millennium Development Goals; NGOs: Non-Governmental Organi-zations; ppm: parts per million;UE: unmitigated emis-sions

Competing interests

The author declares that she has no competing interests

Additional material

Acknowledgements

The author would like to thank Joel Smith, Marie-Karin Godbout, Erik Haites, and members of the United Nations Framework Convention on Climate Change Secretariat for their helpful comments This work was par-tially conducted under contract with the United Nations Framework Con-vention on Climate Change Secretariat.

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